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Breaking an old tradition
CENTENNIAL GUEST EDITORIAL
Breaking an old tradition Henry W. Fields Columbus, Ohio
O
n the 100th anniversary of this Journal, I want to reflect on our state of knowledge. Reading multiple systematic reviews, meta-analyses, and letters to the editors can easily lead one to conclude that the state of orthodontic research is not terribly sophisticated, and that there is some push-back regarding evidence-based care. Our research has been criticized for small sample sizes, unreliable or invalid methods, confounding variables, and multiple biases. Taken as a whole, it is just not great stuff when judged objectively. Why and how did we get here? In the mid 1800s, interest in orthodontic education was limited, and new orthodontists were being produced in very small numbers, mostly through in-office preceptorships. In the late 1800s, orthodontics was introduced into a few predoctoral curricula, largely as didactic offerings.1 About this time, Edward H. Angle began lecturing and writing with the notion that orthodontics should be part of the predoctoral and graduate curriculums. He was unsuccessful and subsequently developed his own Angle School of Orthodontia around the turn of the century. Students spent a few weeks to a few months at Angle's school or one of the other proprietary schools that emerged, each led by a singular person who advocated particular methods and philosophies.1 Although Harvard-Forsyth had a graduate program in orthodontics for several years in the early 1900s, New York City was the site of the first 2 sustainable programs at Columbia University and New York University in 1922. Over the next several years, more programs opened and spread to the Midwest and the West Coast. Each program had as its head a luminary in the growing field.2 On the West Coast, an innovative predoctoral program that included a strong orthodontic component
Professor and Vig/Williams Endowed Chair, Division of Orthodontics, College of Dentistry, Ohio State University, Columbus; chief, Division of Orthodontics, Department of Dentistry, Nationwide Children's Hospital, Columbus, Ohio. Am J Orthod Dentofacial Orthop 2015;148:4-5 0889-5406/$36.00 Copyright Ó 2015 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2015.04.007
4
was begun to bolster care for children. “Curriculum II,” which endured from 1929 to 1969 at the University of California at San Francisco, dominated the final 3 years of dental school with pediatric dental and orthodontic didactic and clinical care. Curriculum II was an anomaly in specialty education with a unique niche as a predoctoral program with graduate content.3 Specialty education took several forms—graduate programs, postgraduate programs, and preceptorships. The graduate programs offered didactic and clinical education with a resulting degree. The postgraduate programs provided an ongoing sequence of education, on less than a full-time basis in some instances, but with a certificate upon completion. A new concept in orthodontic education developed in the 1950s; it was designed to produce more well-trained orthodontists until the university-based training capacity was sufficient to meet the demand. The American Association of Orthodontists preceptor program prepared clinical candidates from 1961 until 1970; orthodontic students were taught by experienced private practitioners in their own offices, using a prescriptive 3-year program with exacting protocols.4 When one considers the history of how orthodontic education evolved, it is easy to see how the specialty could grow, flow, and turn with ideas and views that were not science-based and were provided by a selected few persons. Early formal education struggled. Strong persons entered the picture, filled the void, and founded proprietary schools centered around one personality or philosophy. When graduate programs began in universities, only one strong leader was required to bring the program recognition. The preceptor programs that followed to fill the practitioner void revolved around one teacher and one pupil. All these developments and methods hinged on singular people with their own points of view. Although some tried to reinforce and advocate for the scientific basis of orthodontics, the tradition began with the idea, which remains today, that a strong personality with new or renewed ideas can alter the course of the specialty in positive and negative ways. Still today, continuing education speakers advocate new methods,
Centennial guest editorial
even unproven ones underwritten by orthodontic supply companies, to practitioners looking for better methods of treatment and a competitive edge. The advocate claims that methods are successful but insists that there is inadequate time for documentation and evaluation. By the time the evidence is in hand, the advocate has moved on and has adopted and is propagating another new method with equal vigor. Science had a tough time getting a foothold in orthodontics and has for the entirety of the profession. If this were not the case, orthodontics would not rediscover old ideas with new vigor after they had been discredited years before. How else can we account for the pendulum swing in controversies of extraction vs nonextraction, early vs late treatment, and growth modification vs dental movement?5 If we truly learned from science and our experiences, the travel of the pendulum swing would be reduced, and we would gradually see the pendulum begin to hover over the central truth and not be kick-started again by the mere breath of the same argument years later. This might also explain why many of our advances have been technical and mechanical rather than biological. Some see the specialty entering a period when, for better or worse, there are fewer iconic persons with the ability to bulldoze a skeptical audience or ignite a glow among eager clinicians. Good science is complex and often has little generalizability because it is well controlled, is unbiased, and creates further questions. Different results from similar studies do not randomly occur. They are the results of different methods and measures that sometimes are subtle. Unfortunately, this provides an opening for acceptance of “it works in my hands” or “you can prove anything you want to,” rather than what routinely works after rigorous scientific scrutiny. Understanding evidence-based care, even with a central place in the advanced education guidelines, in a specialty with a current dearth of high-quality studies, takes careful thought and consideration. If a method just makes it easier, cheaper, or more feasible from a practice management
5
perspective, accept the reality. But do not sell it as a scientific advancement. So, where to now? I believe a recent article clearly outlined the long way out.6 Mandate that any study providing data on a given type of treatment (problem) must provide data by using prescribed measures developed by the specialty. New and innovative measures can also be reported, but the basics for comparison must be in place to be acceptable. Furthermore, multiple dimensions of treatment should be measured so that issues relevant to biologists, morphologists, practitioners, and patients alike are advanced. In that manner, we will build for the future and not stifle innovation in treatment or measurement. Let's crown any new soothsayers carefully, or maybe not at all, and let thorough and patient science lead us. ACKNOWLEDGMENTS
Portions of this article were excerpted from: Fields HW. Contemporary orthodontic postgraduate programs as related to the rest of dental specialty advanced education In: Eliades T, Athanasiou A, editors. Orthodontic postgraduate education: a global perspective. Stuttgart, Germany: Thieme; 2015. REFERENCES 1. Wahl N. Orthodontics in 3 millennia. Chapter 3: the professionalization of orthodontics. Am J Orthod Dentofacial Orthop 2005;127: 749-53. 2. Lewis SJ. The development of orthodontic education. J Am Dent Assoc 1934;21:1152-65. 3. Dougherty H. The curriculum II orthodontic program at the University of California at San Francisco School of Dentistry from 1929 until 1969. Am J Orthod Dentofacial Orthop 1999;115:595-7. 4. Hahn GW. The story of the AAO-supervised preceptorship program. Am J Orthod 1971;60:189-95. 5. Wahl N. Orthodontics in 3 millennia. Chapter 11: the golden age of orthodontics. Am J Orthod Dentofacial Orthop 2005;127:749-53. 6. Tsichlaki A, O'Brien K. Do orthodontic research outcomes reflect patient values? A systematic review of randomized controlled trials involving children. Am J Orthod Dentofacial Orthop 2014;146: 279-85.
American Journal of Orthodontics and Dentofacial Orthopedics
July 2015 Vol 148 Issue 1
Breaking an old tradition Henry W. Fields Columbus, Ohio
O
n the 100th anniversary of this Journal, I want to reflect on our state of knowledge. Reading multiple systematic reviews, meta-analyses, and letters to the editors can easily lead one to conclude that the state of orthodontic research is not terribly sophisticated, and that there is some push-back regarding evidence-based care. Our research has been criticized for small sample sizes, unreliable or invalid methods, confounding variables, and multiple biases. Taken as a whole, it is just not great stuff when judged objectively. Why and how did we get here? In the mid 1800s, interest in orthodontic education was limited, and new orthodontists were being produced in very small numbers, mostly through in-office preceptorships. In the late 1800s, orthodontics was introduced into a few predoctoral curricula, largely as didactic offerings.1 About this time, Edward H. Angle began lecturing and writing with the notion that orthodontics should be part of the predoctoral and graduate curriculums. He was unsuccessful and subsequently developed his own Angle School of Orthodontia around the turn of the century. Students spent a few weeks to a few months at Angle's school or one of the other proprietary schools that emerged, each led by a singular person who advocated particular methods and philosophies.1 Although Harvard-Forsyth had a graduate program in orthodontics for several years in the early 1900s, New York City was the site of the first 2 sustainable programs at Columbia University and New York University in 1922. Over the next several years, more programs opened and spread to the Midwest and the West Coast. Each program had as its head a luminary in the growing field.2 On the West Coast, an innovative predoctoral program that included a strong orthodontic component
Professor and Vig/Williams Endowed Chair, Division of Orthodontics, College of Dentistry, Ohio State University, Columbus; chief, Division of Orthodontics, Department of Dentistry, Nationwide Children's Hospital, Columbus, Ohio. Am J Orthod Dentofacial Orthop 2015;148:4-5 0889-5406/$36.00 Copyright Ó 2015 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2015.04.007
4
was begun to bolster care for children. “Curriculum II,” which endured from 1929 to 1969 at the University of California at San Francisco, dominated the final 3 years of dental school with pediatric dental and orthodontic didactic and clinical care. Curriculum II was an anomaly in specialty education with a unique niche as a predoctoral program with graduate content.3 Specialty education took several forms—graduate programs, postgraduate programs, and preceptorships. The graduate programs offered didactic and clinical education with a resulting degree. The postgraduate programs provided an ongoing sequence of education, on less than a full-time basis in some instances, but with a certificate upon completion. A new concept in orthodontic education developed in the 1950s; it was designed to produce more well-trained orthodontists until the university-based training capacity was sufficient to meet the demand. The American Association of Orthodontists preceptor program prepared clinical candidates from 1961 until 1970; orthodontic students were taught by experienced private practitioners in their own offices, using a prescriptive 3-year program with exacting protocols.4 When one considers the history of how orthodontic education evolved, it is easy to see how the specialty could grow, flow, and turn with ideas and views that were not science-based and were provided by a selected few persons. Early formal education struggled. Strong persons entered the picture, filled the void, and founded proprietary schools centered around one personality or philosophy. When graduate programs began in universities, only one strong leader was required to bring the program recognition. The preceptor programs that followed to fill the practitioner void revolved around one teacher and one pupil. All these developments and methods hinged on singular people with their own points of view. Although some tried to reinforce and advocate for the scientific basis of orthodontics, the tradition began with the idea, which remains today, that a strong personality with new or renewed ideas can alter the course of the specialty in positive and negative ways. Still today, continuing education speakers advocate new methods,
Centennial guest editorial
even unproven ones underwritten by orthodontic supply companies, to practitioners looking for better methods of treatment and a competitive edge. The advocate claims that methods are successful but insists that there is inadequate time for documentation and evaluation. By the time the evidence is in hand, the advocate has moved on and has adopted and is propagating another new method with equal vigor. Science had a tough time getting a foothold in orthodontics and has for the entirety of the profession. If this were not the case, orthodontics would not rediscover old ideas with new vigor after they had been discredited years before. How else can we account for the pendulum swing in controversies of extraction vs nonextraction, early vs late treatment, and growth modification vs dental movement?5 If we truly learned from science and our experiences, the travel of the pendulum swing would be reduced, and we would gradually see the pendulum begin to hover over the central truth and not be kick-started again by the mere breath of the same argument years later. This might also explain why many of our advances have been technical and mechanical rather than biological. Some see the specialty entering a period when, for better or worse, there are fewer iconic persons with the ability to bulldoze a skeptical audience or ignite a glow among eager clinicians. Good science is complex and often has little generalizability because it is well controlled, is unbiased, and creates further questions. Different results from similar studies do not randomly occur. They are the results of different methods and measures that sometimes are subtle. Unfortunately, this provides an opening for acceptance of “it works in my hands” or “you can prove anything you want to,” rather than what routinely works after rigorous scientific scrutiny. Understanding evidence-based care, even with a central place in the advanced education guidelines, in a specialty with a current dearth of high-quality studies, takes careful thought and consideration. If a method just makes it easier, cheaper, or more feasible from a practice management
5
perspective, accept the reality. But do not sell it as a scientific advancement. So, where to now? I believe a recent article clearly outlined the long way out.6 Mandate that any study providing data on a given type of treatment (problem) must provide data by using prescribed measures developed by the specialty. New and innovative measures can also be reported, but the basics for comparison must be in place to be acceptable. Furthermore, multiple dimensions of treatment should be measured so that issues relevant to biologists, morphologists, practitioners, and patients alike are advanced. In that manner, we will build for the future and not stifle innovation in treatment or measurement. Let's crown any new soothsayers carefully, or maybe not at all, and let thorough and patient science lead us. ACKNOWLEDGMENTS
Portions of this article were excerpted from: Fields HW. Contemporary orthodontic postgraduate programs as related to the rest of dental specialty advanced education In: Eliades T, Athanasiou A, editors. Orthodontic postgraduate education: a global perspective. Stuttgart, Germany: Thieme; 2015. REFERENCES 1. Wahl N. Orthodontics in 3 millennia. Chapter 3: the professionalization of orthodontics. Am J Orthod Dentofacial Orthop 2005;127: 749-53. 2. Lewis SJ. The development of orthodontic education. J Am Dent Assoc 1934;21:1152-65. 3. Dougherty H. The curriculum II orthodontic program at the University of California at San Francisco School of Dentistry from 1929 until 1969. Am J Orthod Dentofacial Orthop 1999;115:595-7. 4. Hahn GW. The story of the AAO-supervised preceptorship program. Am J Orthod 1971;60:189-95. 5. Wahl N. Orthodontics in 3 millennia. Chapter 11: the golden age of orthodontics. Am J Orthod Dentofacial Orthop 2005;127:749-53. 6. Tsichlaki A, O'Brien K. Do orthodontic research outcomes reflect patient values? A systematic review of randomized controlled trials involving children. Am J Orthod Dentofacial Orthop 2014;146: 279-85.
American Journal of Orthodontics and Dentofacial Orthopedics
July 2015 Vol 148 Issue 1